New York hospital’s PICU celebrates one year without central line infections
On July 7, staff members in the pediatric ICU (PICU) at Steven and Alexandra Cohen Children’s Medical Center of New York (CCMC) celebrated one full year free of central line infections.
The milestone, something that only a small number of ICUs across the country have achieved, was accomplished through adherence to standard infection control practices and a reengineering of the culture of safety within the environment.
“In the traditional environment, the nurses do their thing, the doctors do their thing,” says Peter Silver, MD, chief of critical care medicine at CCMC. “Here we have one team, and everybody’s responsible for everything.”
Silver credits a team mentality as the driving force behind the PICU’s success. All staff members on the unit are empowered to speak up and voice concerns because patient care is seen as everyone’s responsibility.
“You only get in trouble if you don’t talk around here,” Silver says.
A focus on central line infections
CCMC joined a collaborative in summer 2009 sponsored by the National Association of Children’s Hospitals and Related Institutions (NACHRI) that was focused on the reduction of central line infections. The PICU’s 80 full-time nurses and 11 attending physicians were all educated on how to prevent central line infections in pediatric patients, which is rather different than preventing them in adult patients, says Silver.
There are two main instances during which central line infections occur: during insertion and during day-to-day maintenance and care of the line. In pediatric patients, insertion infections account for only 10% of infections, but in adults that number jumps to 90%. This is likely due to the differences in immune responses in these populations, says Silver.
To prevent insertion infections, staff in the PICU, which has 20 beds and sees 1,600 patients each year, utilized a set of practices shared with them through the NACHRI collaborative. These included:
- Changing the scrub from Betadine® soap to chlorhexidine soap
- Scrubbing the site for two minutes
- Total draping of the patient
- Strict hand washing
- Use of gloves, gown, mask, and cap
- Dedicated observer to ensure adherence to practices
To prevent infections related to maintenance, staff members used a different set of practices, also shared via the NACHRI collaborative:
- Daily review of whether the line is necessary (CCMC does this three times per day)
- Prior to every entry into the catheter, 30-second scrub with chlorhexidine
- Standard dressing changes
- Tubing changes every 72 hours, or every 24 when blood is given
One way Silver involved the staff was by hosting a contest for the catchiest 30-second jingle to remind staff members how long to scrub the site. The winning jingle was sung to the tune of “America the Beautiful.”
“Every bedside has a laminated card of our 30-second jingle,” he says. “You need to do things like that to get people to buy in, make it fun, and give them a sense of ownership.”
Achieving a culture of safety
Although using proper infection control practices is important in the prevention of central line infections, building the appropriate culture of safety has also been a key factor in CCMC’s success, says Silver. He says there are three areas that need to be addressed: staff education, accountability and empowerment, and infectious enthusiasm on the part of leadership.
After staff are educated about the culture of safety and the appropriate procedures, they need to be held accountable for their actions, says Silver. As part of the NACHRI collaborative, nurses are empowered to speak up and demand that everyone involved in preventing infections take responsibility for how they insert and maintain central lines. Staff also use a checklist that helps them stay in line with the infection control protocols.
“The nurses are empowered to stop the procedure and say, ‘No, you only scrubbed for a minute and a half—not two minutes,’ ” says Silver. Nurses audit each other’s practices as well as those of the PICU physicians.
To that end, nurses and physicians are encouraged to call each other by their first names because familiarity is important for reinforcing a culture of safety. Once you address someone as “Excuse me, doctor,” there’s a level of formality involved, says Silver.
Ensuring that leadership is not only involved, but excited about efforts is a must. CCMC’s PICU celebrates major milestones along the way, says Silver.
“You have to have total respect and sensitivity for what the frontline troops are doing every day,” he says. The unit held celebrations at every 100-day mark without a central line infection. They also keep a banner on the unit touting how many days it has been free of infections.
Additionally, Silver says he sticks by the adage of “make the right thing to do the easy thing to do.” With that in mind, it’s important to eliminate barriers for staff. The collaborative suggested some changes in practice that helped accomplish this. For example, CCMC placed all of the supplies necessary to insert a central line on a cart that can travel from bedside to bedside, rather than asking nurses to travel all over the unit or to the stock room to find them. They also developed kits for the care of the lines so clinicians didn’t have to search for each piece.
Lastly, CCMC’s PICU has transformed the way it thinks about communication, says Silver. “Nurse participation in rounds is mandatory, and we round on our patients three times a day,” he says. “Part of that participation is the nursing assessment of the central line—appearance, how it’s functioning, and whether it’s still necessary—because a central line that isn’t in place can’t get infected.”
In fact, reducing the number of central line days is a big part of the unit’s efforts and factors in to its achievement of zero infections for one full year. Silver says the PICU has reduced the number of central line days by 25%.
Confronting the naysayers
Because going an entire year without a central line infection is such a rare achievement and because it’s so difficult, there were many who doubted CCMC’s PICU’s ability to attain this goal prior to its participation in the NACHRI collaborative.
“Some of my physician colleagues said, ‘Why are you working so hard on this? Central line infections happen,’ when we were having about one a month,” says Silver.
What helped set staff on the right track and get everyone in the right mind-set was thinking of central line infections as never events. Strive to eliminate them, even though they will sometimes occur, says Silver.
“Sometimes never events happen, meaning that you don’t expect it to happen, you engineer yourself to not have it happen, it’s not accepted that it happens—but it happens,” says Silver. But by simply acknowledging that when they do occur it’s not something the organization accepts, the organization will do everything in its power to prevent them from happening again, he says.
Silver credits collaboration as one of the key factors in the improvement project’s success.
After one year of fostering a team mentality, improving the culture of safety, and utilizing proper infection control techniques, CCMC’s PICU can proudly report that for 2,574 central line days, it had zero infections, compared with the national average of 2.9 infections per 1,000 days.
Patient Safety Monitor (Briefings on Patient Safety), October 2010, HCPro, Inc.